Please provide all of the documents requested below by the due date. The Eligible Professional (EP) should complete Column C.The auditor will complete Column D.

(A)ItemNumber

(B)Requested Documents

C)For Completion by the EP

(D)For Completion by Auditor

Date Sent to Auditor

Method of Delivery (Upload/Email/Mail)

Initial Request Date

2nd Request Date

Date Received

PART I - GENERAL INFORMATION

1

As proof of possession of a certified Electronic Health Record technology system, provide a copy of the Office of the National Coordinator of Health Information Technology (ONC) certification as well as licensing agreements with the vendor or invoices from the time the system was purchased.

2

Please provide a response to the following questions:

At how many offices/facilities do you see your patients?

Do you utilize EHR software in all of these facilities?

3

Could you please supply documentation which proves that 50% or more of your patient encounters during the EHR reporting period have been entered into your Certified Electronic Health Record Technology system (i.e. an appointment log demonstrating all appointments that took place during the reporting period as well as a list of patient encounters from your EHR system.)

PART II - CORE SET OBJECTIVES / MEASURES

4

Provide the supporting documentation (in either paper or electronic format) used in the completion of the Attestation Module responses (i.e. a report from your EHR system that ties to your attestation).

Please Note: If you are providing a summary report from your EHR system as support for your numerators/ denominators, please ensure that we can identify that the report has actually been generated by your EHR (i.e. your EHR logo is displayed on the report, or step by step screenshots which demonstrate how the report is generated by your EHR are provided.)

To support Y/N attestation measures, please supply documentation such as screenshots from your EHR system.

PART III - MENU SET OBJECTIVES / MEASURES

5

Provide the supporting documentation (in either paper or electronic format) used in the completion of the Attestation Module responses (i.e. a report from your EHR system that ties to your attestation).

Please Note: If you are providing a summary report from your EHR system as support for your numerators/ denominators, please ensure that we can identify that the report has actually been generated by your EHR (i.e. your EHR logo is displayed on the report, or step by step screenshots which demonstrate how the report is generated by your EHR are provided.)

To support Y/N attestation measures, please supply documentation such as screenshots from your EHR system.